Provider Demographics
NPI:1316552102
Name:CREDLE, CHRISTIIAN STORM (PSYD)
Entity type:Individual
Prefix:DR
First Name:CHRISTIIAN
Middle Name:STORM
Last Name:CREDLE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-2103
Mailing Address - Country:US
Mailing Address - Phone:732-395-3900
Mailing Address - Fax:
Practice Address - Street 1:907 CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:SHARON HILL
Practice Address - State:PA
Practice Address - Zip Code:19079-1411
Practice Address - Country:US
Practice Address - Phone:610-583-1177
Practice Address - Fax:610-583-1177
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019097103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PS019097OtherLISENCE NUMBER